Clinical Decision Making in Complementary & Alternative Medicine by Matthew Leach


Published on

There are few published texts that address professional practice issues in complementary and alternative medicine (CAM). There are no known works that describe a clinical framework for CAM practice. The majority of texts on CAM to date explore the use or efficacy of specific CAM
interventions, and whilst this text will also highlight evidence-based interventions, it will also inform practitioners how to apply these interventions within a clinical decision-making framework.

Published in: Education, Health & Medicine
  • Be the first to comment

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Clinical Decision Making in Complementary & Alternative Medicine by Matthew Leach

  1. 1. Matthew Leach Sydney Edinburgh London New York Philadelphia St Louis Toronto
  2. 2. Preface Over the past few decades there has been a resurgence of interest in complementary and alternative medicine (CAM), with more than half of the Western population reporting the use of these therapies and at least one in 10 accessing CAM services. During this time, many CAM occupations have transformed from often humble beginnings as cottage industries to what are now recognised as important providers of healthcare and vital members of the integrative healthcare team. Although these changes have been slow in coming, they have been progressive. The increased demand for CAM products and services in the late 20th century was partly driven by a shift in consumer attitudes and need, specifically, the need for holistic, individualised and participatory care and the need for greater choice in healthcare. Regulatory bodies have also shaped the CAM industry, through educa- tional reform, increased regulation of CAM products and the reimbursement to the client of the cost of CAM services through private health insurance providers. The changing face of many CAM occupations, particularly the system-based disciplines such as naturopathy, Western herbalism and traditional Chinese medicine, suggests that these specialties are in the midst of transforming from occupations to professions. While much progress has been made over the past few decades to facilitate the professionalisation of several CAM disciplines, there are still many shortcom- ings that prevent these occupations from achieving full professional status. There is, for instance, a need for greater unity within and across CAM disciplines, although the fractionated nature of the industry does not yet lend itself to unification. Closer alignment with the scientific or evidence-based paradigm is also essential for the professional advancement of CAM occupations. Yet according to findings from a recent Australian survey,1 there is still much to be done before system-based CAM practitioners embrace evidence-based practice to its full extent. Another criterion necessary to the professionalisation of CAM occupations is the development and standardisation of knowledge. While most CAM disciplines share similar philoso- phies and a unique body of knowledge, a systematic and consistent approach to CAM practice within and across disciplines is still missing. Clinical decision Making in Complementary and Alternative Medicine endea- vours to address these shortfalls by introducing a decision-making framework for complementary and alternative medicine (DeFCAM), as well as adding to the unique body of knowledge for CAM. This framework, which consists of six stages, is pri- marily aimed at guiding CAM practitioner thinking, assessment and care without detracting from the philosophical underpinnings of complementary and alternative medicine. Specifically, DeFCAM enables practitioners to deliver care in a system- atic, critical, transparent, efficient and consistent manner, while adhering to the prin- ciples of evidence-based practice. In so doing, it is anticipated that DeFCAM will improve cross-disciplinary communication, clinical outcomes and the quality of cli- ent care. In terms of structure, the text is divided into two parts. Part 1, Theoretical foundations, describes the theoretical foundations of DeFCAM. In this section, each stage of the framework is discussed in detail. Chapter 2 discusses rapport, chapter 3 assessment, chapter 4 diagnosis, chapter 5 planning chapters 6 and 7 application; and ❨xv
  3. 3. Contents ❩ Table 7.1 Challenges facing the integrative healthcare movement 147 Table 7.2 Merits of integrative healthcare 149 Table 8.1 Examples of clinical review instruments 159 Table 8.2 Factors affecting the attainment of client outcomes or client adherence to treatment 159 Table 8.3 Questions for reviewing clinical practice 160 Table 8.4 Questions to facilitate reflective practice 161 xiv❩
  4. 4. ❨ Contents List of tables Table 1.1 Clinical decision-making models utilised in the health careealthcare sector 6 Table 2.1 Questions or phrases that hinder and facilitate client–practitioner collaboration 16 Table 2.2 Practitioner strategies and behaviours that improve client trust, communication and rapport 17 Table 3.1 Principles of rigorous clinical assessment 25 Table 3.2 Core components of the presenting complaint description (ReLOAD FACQS) 26 Table 3.3 Medical components of the health history (FAMMS) 27 Table 3.4 Lifestyle components of the health history (DISEASE) 27 Table 3.5 Socioeconomic components of the health history (FORSEE) 28 Table 3.6 Examples of diagnostic tests that may be requested, performed or interpreted in complementary and alternative medicine practice 31 Table 4.1 Examples of diagnostic reasoning models 104 Table 4.2 Essential requirements of a CAM diagnosis 110 Table 4.3 Examples of CAM diagnoses 110 Table 5.1 Comparing client-centred goals to practitioner-centred goals 122 Table 5.2 Questions to assist clients and CAM practitioners in identifying appropriate treatment goals 124 Table 5.3 Examples of the two-stage planning process, including a general goal and expected outcomes 125 Table 6.1 The hierarchy of evidence 131 Table 6.2 Strength of evidence 132 Table 6.3 Direction of evidence 133 Table 6.4 Application of the evidence-based decision-making framework to CAM practice 136 ❨xiii
  5. 5. Contents ❩ List of figures Figure 1.1 The decision-making framework for complementary and alternative medicine (DeFCAM) 7 Figure 2.1 A CAM practice floor plan that fosters client–practitioner rapport 19 Figure 2.2 Factors that impact on the development of client–practitioner rapport 20 Figure 3.1 CAM assessment process 25 Figure 3.2 Cardiovascular assessment cue card 32 Figure 3.3 Respiratory assessment cue card 39 Figure 3.4 Gastrointestinal assessment cue card 45 Figure 3.5 Urinafigury assessment cue card 53 Figure 3.6 Reproductive assessment cue card 59 Figure 3.7 Integumentary assessment cue card 67 Figure 3.8 Endocrine assessment cue card 72 Figure 3.9 Nervous system assessment cue card 82 Figure 3.10 Musculoskeletal assessment cue card 89 Figure 4.1 The process of inductive reasoning 105 Figure 4.2 The process of deductive reasoning 106 Figure 4.3 CAM diagnostic reasoning approach, demonstrating the central inductive reasoning framework, simultaneous deductive reasoning process (left) and factors informing the process (right) 108 Figure 5.1 Essential criteria for setting goals and expected outcomes 122 Figure 6.1 The evidence based practice paradigm 134 Figure 6.2 The evidence-based decision-making framework 135 Figure 7.1 The consultative–integrative healthcare spectrum 144 Figure 7.2 The integrative healthcare centre model (IHCCM) 152 Figure 8.1 The review process 162 xii❩
  6. 6. Contents List of figures xii List of tables xiii About the author v Acknowledgements vii Preface xv Part 1 – Theoretical foundations 1 A decision-making framework for complementary and alternative medicine 3 2 Rapport 13 3 Assessment 23 4 Diagnosis 100 5 Planning 117 6 Application – Evidence-based practice (EBP) 130 7 Application – Integrative health care (IHC) 143 8 Review 156 Part 2 – Practical application 9 Application of DeFCAM 167 The studies Case study 1 Acne vulgaris 170 Case study 2 Anxiety 179 Case study 3 Asthma 193 Case study 4 Chronic venous insufficiency 207 Case study 5 Dysmenorrhoea 216 Case study 6 Dermatitis/Eczema 228 Case study 7 Irritable bowel syndrome 238 Case study 8 Migraine 249 Case study 9 Osteoarthritis 263 Case study 10 Psoriasis 278 ❨xi
  7. 7. Reviewers Rachel Arthur, BHSc BNat(Hons) (SCU) MACCNEM MNSA MNHAA MANTA, Lecturer, School of Health and Human Sciences, Southern Cross University, NSW, Professional & corporate educator, private practitioner, NSW. Liesl Blott, BHSc (WHerbal Med) (ACNM), AdvDipNat (ACNM) BPharm (UWits), PGDip MM (UNISA), lecturer, Faculty of Health Science, Curtin University. Jenny Wilkinson, BSc (Hons) (Qld), PhD (Macq), GradDipFET (SQld), MHEd (Macq), Associate Professor in Physiology, Charles Sturt University, NSW. Emily Bradley, ND (SSNT), MANTA, lecturer and clinical supervisor, Naturopthy Department, Endeavour College of Natural Health and Southern School of Natural Therapies, practicing naturopath, Melbourne. ❨ix
  8. 8. Acknowledgements Many years have passed since the idea for this book was first conceived. But with much planning, research, time, effort and writing, the idea has developed into an informative text for the complementary and alternative medicine (CAM) profession. However, no man is an island unto himself, and this text would not have been possible without the support of some exceptional individuals. First and foremost I need to acknowledge the tremendous support provided by my family, specifically, my wife Pam, son Haiden and daughter Mikaela. In spite of the many late nights and very early mornings, and the constant requests for one more minute of time, they were always there for me, and for that, I am extremely thankful. Their unconditional love and faith in me was also a constant reminder of the most important thing in my life – my family. And of course, I cannot dismiss my two study companions, my dogs Arum and Raphael, who were often by my side on those many late nights. To my friends, students and colleagues, thank you for your encouragement and for believing in me, listening to me and sharing your wisdom, thoughts and insights into CAM, health and healthcare. For this I will be forever grateful. I am also grateful for the support, understanding and guidance offered by the Elsevier team, especially Sophie Kaliniecki and Sabrina Chew, who have been there right from the start. Thank you to Rachel Arthur, Blott, Jenny Wilkinson and Emily Bradley, the reviewers of this book whose valuable feedback helped shape the text. To the current and future generations of CAM practitioners, it is for you that I dedicate this book, and it is in you that I wish to instill hope and passion for the professional advancement of the greater CAM profession. Parts of this book have been reproduced from previous works of the author with written permission from Elsevier, the Journal of the Australian Traditional Medicine Society, Blackwell Publishing and the Berkeley Electronic Press. Dr Matthew Leach ❨vii
  9. 9. About the author Dr Matthew J Leach RN, DipAppSci (Nat), DipClinNutr, BN (Hons), PhD, Registered Nurse, Naturopath, Research Fellow, University of South Australia, Adelaide, is a research fellow in the health economics and policy group at the University of South Australia and was previously a registered nurse, naturopath and lecturer in naturopathy and health sciences. Dr Leach completed his Bachelor of Nursing degree in 1994, followed by a Diploma of Applied Science (Naturopathy) in 1998, a Bachelor of Nursing (Honours) degree in 2000 and a Diploma of Clinical Nutrition in 2008. His PhD, which he completed in 2005, examined the clinical feasibility of horsechestnut seed extract in the management of venous leg ulceration. Since then, he has been driven to improving the evidence base of complementary and alternative medicine (CAM) as well as the professionalisation of CAM services. This is evidenced by the type of research conducted by Dr Leach, the papers and book chapters he has published in these areas and the many fora, seminars and international conferences he has presented at. ❨v
  10. 10. Preface ❩ chapter 8 review. Part 2, Case studies (chapter 9) is dedicated to the clinical applica- tion of the decision-making framework for complementary and alternative medicine. This part, exemplified by a number of clinical scenarios, demonstrates to readers how DeFCAM can be applied in clinical practice. As well as promoting the delivery of professional excellence in complemen- tary and alternative medicine, it is hoped that this text will serve as an impetus for positive change in the CAM industry and, by forging unity among the many CAM disciplines, help to facilitate the professionalisation of these occupations. Dr Matthew Leach Reference 1 Leach MJ. Gillham D. (2009) Attitude and use of evidence-based practice among complementary medicine practitioners: a descriptive survey. 2nd North American Research Conference on Complementary & Integrative Medicine, Minneapolis, 12–15 May. xvi❩
  11. 11. PA R T 1 Theoretical Foundation
  12. 12. 1 A decision-making framework for complementary and alternative medicine Chapter overview The safe, effective and efficient delivery of client care is informed primarily by sound clini- cal decision making. Strategies that guide practitioners through the process of decision making may not only foster professional excellence in complementary and alternative medicine (CAM) practice, but also help to improve the quality of client care. An example of such a strategy is the decision-making framework for complementary and alternative medicine (DeFCAM). In this first chapter, an overview of DeFCAM is provided, which aims to assist readers in understanding the context of the following chapters and the circum- stances in which the framework can be applied to CAM practice. Learning objectives The content of this chapter will assist the reader to: • identify a range of decision-making frameworks used in clinical practice • understand the sequence and purpose of each stage of DeFCAM • recognise the benefits and limitations of DeFCAM • understand how DeFCAM can facilitate clinical decision making. Chapter outline • Introduction • CAM philosophy • Clinical decision-making models • The decision-making framework for complementary and alternative medicine (DeFCAM) • Rapport • Assessment • Diagnosis • Planning • Application • Review • Summary Introduction ‘Complementary and alternative medicine’ (CAM) is an overarching term that encapsulates a diverse range of modalities considered to be outside the scope of orthodox medicine. According to the National Center for Complementary and Alter- native Medicine in the US1 and the National Institute of Complementary Medicine in Australia,2 both of which are leading authorities in CAM research, these thera- pies can be divided into five distinct categories, including whole medical systems (such as naturopathy, homeopathy, Western herbalism, Ayurveda, indigenous and traditional Chinese medicine (TCM); energy medicine (including therapeutic touch, flower essences and Reiki); biologically based interventions (such as nutrients, plant ❨3
  13. 13. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE and animal products); manipulative therapies (including massage, chiropractic, osteopathy and reflexology), and mind–body interventions (such as tai chi, yoga, meditation and progressive relaxation). Given the recent trend towards integrative medicine, the line separating CAM from orthodox medicine is becoming less distinct. This is further perpetuated by vague definitions of CAM. NCCAM,1 for example, defines CAM as ‘a group of diverse medical and healthcare systems, practices, and products that are not pres- ently considered to be part of conventional medicine’. Defining CAM by what it is not is no longer appropriate given the changing face of healthcare and the inte- gration of CAM into medical, nursing and allied health curricula. CAM is more fittingly defined as a diverse group of health-related modalities that promote the body’s innate healing ability in order to facilitate optimum health and wellbe- ing, while retaining a core focus on holism, individuality, education and disease prevention. Consumer interest in these therapies has escalated over the past few decades. In fact, more than fifty per cent of the Western population,3 including the Australian,4,5 US6 and Japanese populations,7 have used CAM at least once over a 12-month period. Biologically based interventions, such as nutrient supple- ments and herbal medicines, and manipulative therapies, such as massage and chiropractic, are among those demonstrating the highest level of use. Over the same period, close to ten per cent of UK adults,8 twelve per cent of US adults,6 and twenty-three9 to forty-four per cent of Australians5 have consulted a CAM practitioner; chiropractic and osteopathy were the most commonly used services. The growing interest in CAM across the globe can be attributed to a number of factors. Although earlier studies signalled consumer dissatisfaction with ortho- dox medicine as a leading cause of CAM use,3 more recent reports indicate that an aspiration for active healthcare participation, greater disease chronicity and severity, holistic healthcare beliefs, and an increase in health-awareness behav- iour are more likely to predict CAM use.10–12 These transformations in consumer attitude and health behaviour have parallelled changes in the way many CAM specialties practise. The shift towards evidence-based practice, along with issues concerning educa- tion and regulation, are now shaping the future of many system-based modalities, particularly naturopathy, Western herbalism and TCM. These changes suggest that the aforementioned specialties may be in the process of professionalisation, that is, transforming from occupation to profession. Unification of the CAM profession, controlled entry into the vocation (i.e. occupational closure), closer alignment to the mainstream scientific-evidence-based practice paradigm, and the development and standardisation (or codification) of knowledge are all essential criteria for the professionalisation of CAM occupations.13,14 Although codification involves claim- ing a unique body of knowledge, it also requires an understanding of how that knowledge can be applied to practice.15 Clinical decision-making models play a pivotal part in this translational process. This chapter will therefore introduce the reader to a decision-making framework for complementary and alternative medicine (DeFCAM), and demonstrate how this framework may facilitate the application of CAM knowledge into clinical practice. The uptake of such a model may also help to espouse the ongoing development of CAM and enhance the professionalism of CAM practitioners. 4❩
  14. 14. 1 ❨ A decision-making framework for complementary and alternative medicine CAM philosophy The practice of CAM is guided by the art, science and principles of each profes- sion. Even though the art and science of the CAM therapies are distinctly different from each other, many of these professions share similar philosophies. Some of the core principles underlying these philosophies that are shared by therapies such as naturopathy, Ayurveda, TCM, chiropractic, osteopathy, Western herbalism and homeopathy,16–24 are as follows: • CAM is client-centred and individualised • CAM treats each person holistically • CAM identifies and manages the underlying cause of the person’s condition • CAM supports the body’s innate healing ability and/or vital energy • CAM helps to restore balance or homeostasis • CAM should not cause harm • CAM alleviates suffering • CAM focuses on the prevention of illness • CAM optimises health, wellness and wellbeing. These principles are central to understanding the unique approach of CAM. More importantly, these principles serve to inform clinical decision making, particularly decisions relating to the assessment and treatment of an individual patient (including the identification of the underlying cause of the condition and the provision of holistic care). Even so, these doctrines are neither systematic nor process oriented and as such, are unable to methodically direct practitioners through the CAM consultation or decision-making process. For graduates of CAM, the absence of a clear framework could make transition from student to clinician difficult. One way to facilitate this transition is by bridging the gap between the philosophical foundations of CAM and the requirements of modern-day clinical practice (i.e. avoiding client harm by adopting the best available evidence, for- mulating client-centred treatment goals, evaluating care to ensure balance has been restored), through the provision of a CAM-specific clinical decision-making framework. Clinical decision-making models Over the past few decades, a number of decision-making models have emerged within the healthcare sector. The general aim of these frameworks was to guide prac- titioners through the process of decision making in often complex clinical environ- ments. Examples of some of the more common models used in clinical practice are highlighted in Table 1.1. Many of these frameworks were originally designed to improve documentation in the healthcare sector rather than guide clinical deci- sion making. SOAP, DAP, OHEAP and SNOCAMP, for example, while providing a simple, systematic and consistent approach to documentation in the clinical envi- ronment, provide very little direction for practitioners in the management of client problems. Fortunately, several models have since emerged that attempt to address this problem. One of the earliest participative decision-making frameworks to surface in ortho- dox medicine was that developed by Ballard-Reisch (1990).25 Originally designed for physicians, the eight-stage participative decision-making model aimed to provide a more client-centred and structured approach to client care. Although the need for a participative approach was timely and well justified, the stages of the model lacked ❨5
  15. 15. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE Table 1.1: Clinical decision-making models used in the healthcare sector DAP Data, assessment, plan FARM Findings, assessment, recommendations/resolutions, management HOAP History, observations, assessment, plan Nagelkerk (2001) model Problem, assessment, diagnoses, diagnostics, single diagnosis, treatment plan Nursing process Assessment, diagnosis, planning, implementation, evaluation Nutrition care process Assessment, diagnosis, implementation, monitoring and evaluation Participative Information gathering, information interpretation, decision-making model exploration of treatment alternatives, criteria establishment (Ballard-Reisch 1990) for treatment, weighing of alternatives against criteria, alternative treatment selection, decision implementation, evaluation of implemented treatment Prion (2008) model Situation prime, gather cues, determine relevant/non- relevant cues, cue grouping, problem identification, patient status, cause hypothesis, intervention, gather more information OHEAP Orientation, history, exam, assessment, plan SNOCAMP Subjective data, nature of presenting complaint, objective data, counselling, assessment, medical decision making, plan of treatment SOAP Subjective data, objective data, assessment, plan sufficient description. There is also little evidence to indicate that, to date, this pro- cess has been accepted or taken up by the wider medical community. This is not to say that other participative models have not been adopted by physicians, only that the use of such frameworks has not been well published. A well-documented decision-making framework is the nursing process. This model has been widely accepted by the nursing community and is recognised internation- ally and integrated into most nursing curricula.26 In essence, the process provides a client-centred framework for nursing practice ‘by which nurses use their beliefs, knowledge, and skills to diagnose and treat the client’s response to actual and poten- tial health problems’.26 The benefits that the nursing process delivers to the nursing profession have been recognised by other disciplines, including the dietetics community, which has led to the subsequent development of the nutrition care process.27,28 It is not surprising, therefore, that there is considerable overlap between the two processes. In fact, there are many similarities between most decision-making models, including the Prion29 clinical reasoning model, Nagelkerk30 diagnostic reasoning process and the aforementioned frameworks. The key themes that arise from all of these models are assessment, diagnosis, planning, implementation and evaluation. Another concept that is implied in the Ballard-Reisch model25 but not explicitly stated in any other decision-making process, yet a component that is critical to all client– practitioner interactions, is rapport. Incorporating rapport into a clinical decision- making framework, together with the five themes listed above, would in effect create a more complete, systematic and structured approach to the management of client problems. DeFCAM is therefore one of only a few, if not the only known model to 6❩
  16. 16. 1 ❨ A decision-making framework for complementary and alternative medicine adequately capture all of these themes within one process. Although the develop- ment of such a model could be perceived by some as merely following the trends of other professions, there is in fact real merit for the CAM profession in adopting such a framework, which the following section alludes to. The decision-making framework for complementary and alternative medicine (DeFCAM) DeFCAM is a systematic clinical reasoning framework developed by the author specifically for CAM and integrative healthcare practitioners. The six stages of the process include rapport, assessment, diagnosis, planning, application and review (Figure 1.1). The process is primarily aimed at guiding CAM practitioner thinking, assessment and care, and, as such, is likely to generate benefits for the CAM practi- tioner, the client and members of the integrative healthcare team, including: • an increase in professional autonomy, status and accountability31 • improvements in client outcomes • greater consistency with clinical documentation • clearer treatment priorities • improvements in quality of care32 • a reduction in decision-making error 32 • greater transparency of decision-making process • greater efficiency and improved focus of consultations • improvements in intra- and interprofessional communication. While DeFCAM is displayed in a linear fashion, and maybe applied as such, the process is not unidirectional. In fact, each stage of the process is interlinked because just as in clinical practice, the acquisition of new information requires a CAM prac- titioner to shift between various stages of assessment, diagnosis and planning until an appropriate treatment plan is developed. Still, the six stages of DeFCAM are Rapport Evidence-based practice Assessment Critical analysis Profession-specific. Diagnosis principles and philosophies Planning Practitioner knowledge, skills and scope of practice Application Client income, culture, values and education Review Figure 1.1: The decision-making framework for complementary and alternative medicine (DeFCAM) ❨7
  17. 17. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE presented in a logical order because each phase of the process acts as a prerequisite for subsequent stages. As illustrated in Figure 1.1, there are a number of concepts that overarch DeFCAM. This is because each of these constructs exercises significant influence on a CAM practitioner’s decision making. In particular, each factor directs how a clinician should assess a client, how the data should be interpreted and what interventions should be selected. By taking these elements into consideration, a CAM practitioner can make attempts to resolve any limitations in their decision-making style in order to deliver more effective clinical care. To summarise at this point, DeFCAM enables CAM practitioners to systemati- cally assess, diagnose, plan, treat and review client-centred health problems in accor- dance with CAM philosophy. An introduction to each of the six-stages of DeFCAM, including how these phases address the core principles of CAM philosophy, will now follow. Rapport Establishing client rapport is the first and most important phase of DeFCAM. By developing rapport with the client, communication between the practitioner and client may improve, as may assessment, treatment compliance and the achieve- ment of expected treatment outcomes.33,34 Even though a therapeutic relationship may develop throughout the consultation, it is important that time is allocated at the beginning of the visit to build client trust. In order to develop trust and decrease client anxiety, the practitioner should introduce themselves to the client and allow the individual to verbalise what they expect from the consultation.33 The CAM practi- tioner may also build trust and strengthen client rapport by being open, empowering, empathetic, objective, honest, non-judgemental, flexible, consistent, committed and interested in the health and welfare of the client.33–35 These attributes should not only be expressed verbally, but also non-verbally through facial expressions, eye contact and posture.33–35 Effective communication and optimal client–practitioner interac- tion may be further facilitated by identifying and respecting differences in client age, gender, developmental stages, cognitive ability, values, beliefs and culture.35 Assessment The assessment phase of DeFCAM involves the acquisition, validation and organi- sation of client information, and the identification of factors that may influence client health and wellbeing. Given that assessment informs every succeeding stage of DeFCAM, the accuracy and inclusivity of the process will almost certainly impact on client outcomes. By following a transparent and systematic assess- ment process, clinicians may be able to enhance the quality of clinical assess- ment by reducing the potential for data omission. One way CAM practitioners may approach clinical assessment is through the use of theoretical models, such as Maslow’s hierarchy of human needs36 or the Neuman systems model.37 Even though these models are useful for recognising pertinent physiological, social or psychological needs of a client, they do little to guide the practitioner through the clinical assessment process overall. This is also the case for traditional clini- cal methods, including the head-to-toe and body systems approaches. The CAM assessment process addresses these limitations by providing a more complete, holistic and systematic approach to clinical assessment, incorporating not only the 8❩
  18. 18. 1 ❨ A decision-making framework for complementary and alternative medicine health history and physical examination, but also pertinent diagnostics, thereby enabling CAM practitioners to effectively identify the underlying cause of the presenting condition. The collection of detailed information also gives rise to a more informed CAM practitioner, who is capable of making prompt and appropri- ate decisions about the need for referral. This process is described in greater detail in chapter 3. Diagnosis In the third phase of DeFCAM, data acquired from the client assessment are clus- tered into logical groups, which enables hypotheses or diagnoses to be generated. This process, known as diagnostic reasoning,35 is critical to the generation of clinical diagnoses. Even though CAM practitioners and other non-medical health profes- sionals are not legally permitted to formulate ‘medical’ diagnoses, at least not in Australia,38 some professions, including nursing and dietetics, have overcome this practice limitation by developing a list of diagnoses that they can legally identify and treat.CAM practitioners could follow a similar path to that of these professions and establish their own set of CAM diagnoses in order to avoid litigation around claims of practising medicine. As with nursing and nutrition diagnoses, a CAM diagnosis also consists of a client-centred problem (actual or potential) and the aetiology of the problem.33,39 Such an approach benefits practitioners because the problem component indi- cates what the client outcome should be at the review stage, whereas the aeti- ology component directs the clinician towards the cause of the condition, and thus points the practitioner towards an appropriate approach to treatment.26 As a result, CAM diagnoses may provide a framework for the delivery of CAM treat- ment,39 and thereby link CAM philosophy to clinical practice (i.e. identifying and treating the cause of the complaint), and improve client prognosis and management. Planning The planning phase of DeFCAM focuses on the development of goals in order to identify and prioritise strategies that may prevent, reduce or resolve client problems, or that facilitate or augment client function. But before these goals can be developed, client problems must first be prioritised. One model that is often used to prioritise client problems is Maslow’s hierarchy of needs.26 However, Maslow’s model does not inform practitioners how to prioritise within each of the six needs; for instance, what physiological problems should a practitioner treat first? Determining what CAM diagnosis to initially address should be ascertained by the level of risk that the problem poses to the client, with conditions demonstrating a higher risk of harm demanding a higher priority of care.35,39 Once CAM diagnoses have been prioritised, the most important diagnosis can then be used to formulate the goals of treatment. These goals should be client-centred, individualised, observable, measurable, mutually derived and realistic, with each goal addressing only one problem and one outcome.35,39 Treatment goals must also take into consideration the cost of treatment, available resources, client age, environment, values, beliefs and culture, as well as social status, client self-effi- cacy, motivation and readiness to change, and the client’s cognitive, physical and emotional capacity.40,41 ❨9
  19. 19. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE Application After CAM diagnoses have been formulated and treatment goals and expected outcomes established, appropriate interventions may then be commenced. As with the planning phase, the treatment options need to be negotiated between the CAM practitioner and the client in order to enhance independence, control, dignity and self-esteem.40 Client involvement in clinical decisions may also improve treat- ment compliance and thus facilitate progression towards expected outcomes. The treatments should also be aimed at achieving the goals identified in the planning stage. Due to the eclectic nature of CAM practice, the diversity of CAM education around the globe and personal preference, very few CAM practitioners are likely to employ the same approach, so it would be inappropriate to dictate which therapies CAM practitioners should prescribe for specific conditions, though it is recommended that the choice of interventions be based on the best available evidence so as to maximise improvements in client outcomes and the quality of care, and to minimise harm and suffering.42 This concept of evidence-based practice and how it applies to CAM practice is discussed in greater detail in chapter 6. Therapies that are supported by clinical evidence, which may be integrated into CAM practice, are outlined in chapter 9. Review The review stage of the decision-making framework utilises assessment techniques to determine whether the treatment approach was effective, if the expected outcomes of client care were achieved,35 if illness was prevented and whether homeostasis was restored. Clinicians need to appreciate that clients may find it difficult to achieve the expected outcomes of treatment if a practitioner’s knowledge base and level of skill are inadequate, and if the client lacks understanding, self-efficacy or is not involved in the treatment process.35,43 The achievement of treatment goals may be facilitated by involving clients in DeFCAM, and by CAM practitioners engaging in reflective prac- tice. This rational and conscious process of systematically and rigorously reflecting on one’s practice enables clinician’s to challenge existing approaches and to learn from one’s actions.44 Summary At present, there is a paucity of universally recognised, clearly constructed, sys- tematic decision-making frameworks to guide the practice of system-based CAM. In order for many systems of CAM to develop professionally, a body of knowledge must be developed and codified. The development of DeFCAM endeavours to facilitate the professionalisation of these CAM systems and to improve clinical reasoning in CAM practice by providing a struc- tured process for clinical care. DeFCAM consists of six interrelated stages, includ- ing rapport, assessment, diagnosis, planning, application and review. These stages are best remembered by the acronym RADPAR. It is envisaged that this framework will provide the necessary foundations for the development of a codified knowledge base for CAM disciplines in order to improve professional status, quality of care and client outcomes. The close alignment of DeFCAM with CAM philosophy also ensures that the core principles of CAM practice have not been discounted. The assessment phase of DeFCAM, for example, addresses the principle of holism and 10❩
  20. 20. 1 ❨ A decision-making framework for complementary and alternative medicine the need to identify the cause of the presenting condition; CAM diagnosis focuses on treating the primary cause of the complaint, as well as preventing illness; the planning approach maintains client-centredness and individualism; application applies the concept of evidence-based practice to minimise harm, optimise health and wellbeing, and alleviate suffering; and review assesses whether the prevention of illness and the restoration of homeostasis has been attained. A more detailed dis- cussion of each of these stages is presented in the chapters that follow, beginning with rapport. Learning activities 1 Compare and contrast the structures of different models of clinical decision making. 2 Identify, and briefly describe, each of the six stages of DeFCAM. 3 Describe some of the benefits of DeFCAM to the practitioner, profession and the client. 4 Outline some of the possible limitations of DeFCAM. 5 In relation to your own specialty, explain how DeFCAM is compatible and/or incompatible with the principles and philosophy of your profession. 6 If you could add another stage to DeFCAM, what would that stage be? Explain how this stage would enable DeFCAM to improve CAM practitioner thinking, assessment and care. References 1. National Center for Complementary and Alternative 9. Lin V et al (2006) The Practice and Regulatory Medicine (NCCAM). (2000) What is CAM? NCCAM, Requirements of Naturopathy and Western Herbal Med- Maryland. Accessed at < icine. Melbourne: Government of Victoria, Department whatiscam/overview.htm>, 1 March 2009. of Human Services. 2. National Institute of Complementary Medicine (NICM). 10. Busato A et al (2006) Health status and healthcare utili- (2009) About complementary medicine. Sydney: sation of patients in complementary and conventional NICM. Accessed at < primary care in Switzerland: an observational study. view/14/17/>, 1 March 2009. Family Practice, 23(1): 116–24. 3. Leach MJ. (2004) Public, nurse and medical practitio- 11. Robinson A. Chesters J. Cooper S. (2007) People’s ner attitude and practice of natural medicine. Comple- choice: complementary and alternative medicine mentary Therapies in Nursing and Midwifery, 10(1): modalities. Complementary Health Practice Review, 13–21. 12(2): 99–119. 4. MacLennan AH. Myers SP. Taylor AW. (2006) The con- 12. Sirois FM. Purc-Stephenson RJ. (2008) Consumer tinuing use of complementary and alternative medicine decision factors for initial and long-term use of com- in South Australia: costs and beliefs in 2004. Medical plementary and alternative medicine. Complementary Journal of Australia, 184(1): 27–31. Health Practice Review, 13(1): 3–20. 5. Xue CCL et al (2007) Complementary and alternative 13. Cant S. Sharma U. (1996) Professionalization of medicine use in Australia: a national population-based complementary medicine in the United Kingdom. survey. Journal of Alternative and Complementary Complementary Therapies in Medicine, 4: 157–62. Medicine, 13(6): 643–50. 14. Hirschkorn KA. (2006) Exclusive versus everyday 6. Barnes PM et al (2004) Complementary and alterna- forms of professional knowledge: legitimacy claims tive medicine use among adults: United States, 2002. in conventional and alternative medicine. Sociology of Seminars in Integrative Medicine, 2(2): 54–71. Health and Illness, 28(5): 533–57. 7. Hori S et al (2008) Patterns of complementary and 15. Sharma U. (1995) Professions, power and the patient: alternative medicine use amongst outpatients in Tokyo, some more useful concepts. In: Complementary medi- Japan. BMC Complementary and Alternative Medicine, cine today: practitioners and patients. Sharma U, editor. 8: 14–23. London: Routledge. 8. Thomas K. Coleman P. (2004) Use of complementary 16. Cassidy CM. (2001) Social and cultural context of com- or alternative medicine in a general population in Great plementary and alternative medical systems. In: Fun- Britain. Results from the National Omnibus survey. damentals of complementary and alternative medicine. Journal of Public Health, 26(2): 152–7. Micozzi MS, editor. Philadelphia: Churchill Livingstone. ❨11
  21. 21. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE 17. Ebrall PS. (2003) Chiropractic. In: An introduction to 31. Higgs J. (2008) Clinical reasoning in the health pro- complementary medicine. Robson T, editor. Sydney: fessions. In: Clinical reasoning in the health profes- Allen & Unwin. sions. 3rd ed. Higgs J, editor. Amsterdam: Elsevier/ 18. Howden I. (2003) Homeopathy. In: An introduction to Butterworth Heinemann. complementary medicine. Robson T, editor. Sydney: 32. Dowding D. Thompson C. (2002) Decision analysis. Allen & Unwin. In: Clinical decision making and judgement in nursing. 19. Lucas N. Moran R. (2003) Osteopathy. In: An intro- Thompson C, Dowding D, editors. Edinburgh: Churchill duction to complementary medicine. Robson T, editor. Livingstone: 131–45. Sydney: Allen & Unwin. 33. DeLaune SC. Ladner PK. (2006) Fundamentals of nurs- 20. Matthews S. (2003) Ayurveda. In: An introduction to ing: standards and practice. 3rd ed. Albany: Thomson complementary medicine. Robson T, editor. Sydney: Delmar Learning. Allen & Unwin. 34. Leach MJ. (2005) Rapport: a key to treatment success. 21. Myers S et al (2003) Naturopathic medicine. In: An Complementary Therapies in Clinical Practice, 11(4): introduction to complementary medicine. Robson T, 262–5. editor. Sydney: Allen & Unwin. 35. Harkreader H. Hogan MA. Thobaben M. (2007) Fun- 22. Pizzorno JE. Murray MT. (2006) Textbook of natural damentals of nursing: caring and clinical judgement. medicine. 3rd ed. Philadelphia: Elsevier. 3rd ed. Philadelphia: Elsevier Saunders. 23. Patching van der Sluijs CG. Bensoussan A. (2003) 36. Taylor C et al (2008) Fundamentals of nursing: the Traditional Chinese medicine. In: An introduction to art and science of nursing care. 6th ed. Philadelphia: complementary medicine. Robson T, editor. Sydney: Wolters Kluwer/Lippincott Williams & Wilkins. Allen & Unwin. 37. Ume-Nwagbo PN. DeWan SA. Lowry LW. (2006) 24. Wohlmuth H. (2003) Herbal medicine. In: An intro- Using the Neuman systems model for best practices. duction to complementary medicine. Robson T, editor. Nursing Science Quarterly, 19(1): 31–5. Sydney: Allen & Unwin. 38. Weir M. (2007) Complementary medicine: ethics and 25. Ballard-Reisch DS. (1990) A model of participative law. 3rd ed. Ashgrove: Prometheus Publications. decision making for physician–patient interaction. 39. Crisp J. Taylor C. (2008) Potter and Perry’s fundamen- Health Communication, 2(2): 91–104. tals of nursing. 3rd ed. Sydney: Elsevier. 26. Iyer PW. Taptich BJ. Bernocchi-Losey D. (1995) Nursing 40. Kozier B et al (2004) Fundamentals of nursing: process and nursing diagnosis. 3rd ed. Philadelphia: concepts, process, and practice. 7th ed. Upper Saddle WB Saunders. River: Pearson Education. 27. Bueche J et al (2008) Nutrition care process and model 41. Treasure J. Maissi E. (2007) Motivational interviewing. Part I: the 2008 update. Journal of the American Dietetic In: Cambridge handbook of psychology, health and Association, 108(7): 1113–17. medicine. 2nd ed. Ayers S et al, editors. Cambridge: 28. Lacey K. Pritchett E. (2003) Nutrition care process and Cambridge University Press. model: ADA adopts road map to quality care and out- 42. Leach MJ. (2006) Evidence-based practice: a frame- comes management. Journal of the American Dietetic work for clinical practice and research design. Interna- Association, 103(8): 1061–72. tional Journal of Nursing Practice, 12: 248–51. 29. Prion S. (2008) The case study as an instructional 43. Leach MJ. (2007) Revisiting the evaluation of clini- method to teach clinical reasoning. In: Clinical reason- cal practice. International Journal of Nursing Practice, ing in the health professions. 3rd ed. Higgs J, editor. 13(2): 70–4. Amsterdam: Elsevier/Butterworth Heinemann. 44. Rolfe G. Freshwater G. Jasper D. (2001) Critical 30. Nagelkerk J. (2001) Clinical decision-making in reflection for nursing and the helping professions: primary care. In: Diagnostic reasoning: case analysis in a user’s guide. Basingstoke: Palgrave. primary care practice. Nagelkerk J, editor. Philadelphia: WB Saunders. 12❩
  22. 22. Case 1 Acne vulgaris/rosacea Description of acne vulgaris/rosacea Definition Acne is an integumentary disorder that affects the pilosebaceous units (acne vulgaris) and/or the underlying blood vessels (rosacea) of the skin. Some of the variants of the disease include acne vulgaris, acne conglobata, acne fulminans, acne excorié, mature onset, pyoderma faciale, rosacea, neonatal and infantile acne. Epidemiology Males and females of all ages can be affected by acne;1 however, the type of acne can vary between sexes. The vulgaris, conglobata and fulminant variants of acne, for example, are most prevalent among adolescent males, while acne excorié, rosacea, mature onset and pyoderma faciale are more likely to manifest in women.1 Aetiology and pathophysiology Many factors can be implicated in the pathogenesis of acne, including genetic, hormonal, infectious, dietary and environmental elements. In terms of hormonal influence, it is believed that elevated androgen levels increase sebum production and abnormal follicu- lar keratinisation and desquamation, which leads to the blockage of pilosebaceous units and the formation of comedones.1 The peak elevation in androgen, sebum and growth hormone levels during the adolescent period provides some explanation for the increased prevalence of this condition during adolescence.2 Findings from a case study of 34 men and women with acne adds further support to the relationship between androgen levels and acne lesion count.2 The bacterium Propionibacterium acnes is another contributing factor in acne develop- ment. This is because the bacterium promotes inflammation by releasing chemotactic factors and proteases while hydrolysing sebum into proinflammatory free fatty acids.1,3 In rosacea, an underlying vascular defect may be responsible,3 although the actual aetiol- ogy of this disorder remains unclear. What is apparent is that rosacea can be triggered by a range of exogenous and endogenous stimuli, including cold or hot weather, wind, sun exposure, exercise, hot baths, emotional stress, alcohol, spicy foods, cosmetics and hot drinks.4 Other environmental factors that may be implicated in the pathogenesis of acne include medications (e.g. steroids, anticonvulsants), occlusive objects (e.g. shirt collars, hel- mets), topical agents (e.g. cosmetics, lotions, creams) and perspiration.4,5 The chronic consumption of foods with a high glycaemic index or glycaemic load also contributes to acne development by promoting hyperinsulinaemia and insulin resistance. This can be followed by elevated free levels of insulin growth factor and androgens, and a subsequent rise in keratinocyte proliferation, sebum production and acne formation.6 Clinical manifestations Acne can range in severity from mild to severe. In mild cases, acneiform lesions might be limited to open (blackheads) and closed (whiteheads) comedones, and papules. In more severe cases, inflamed papules, pustules, nodules and cysts may develop, which can lead to scarring.1,3 The presence of these lesions, as well as scarring, can impact negatively on the psychological wellbeing of the client and their family. Systemic manifestations of the disease can also present in certain variants, such as acne fulminans, with symptoms that include pyrexia, malaise, arthralgia and weight loss.3 In most cases, acneiform lesions are confined to the face, upper back and chest where pilosebaceous units are most abun- dant. In rosacea, lesions are generally localised to the face and are often accompanied by facial erythema, oedema and telangiectasia.5 170❩
  23. 23. 1 ❨ Case 1: Acne vulgaris/rosacea Clinical case 16-year-old male with acne vulgaris to the face and upper back Rapport Adopt the practitioner strategies and behaviours highlighted in Table 2.1 (chapter 2) to improve client trust, communication and rapport, as well as the accuracy and comprehensiveness of the clinical assessment. Assessment Once measures have been put into place to build client–practitioner rapport, the clinician can begin the clinical assessment. Health history History of presenting condition A 16-year-old adolescent presents with concerns about long-standing acne to the face, as well as to the forehead, nose and cheeks, and to the upper back. The lesions began to emerge at the age of 13 and have since gradually increased in number and severity. When applied twice daily, five per cent benzoyl peroxide reduces the inten- sity of the inflammation, but chocolate and stress seem to aggravate the condition. A recent course of broad-spectrum antibiotics, prescribed by the client’s general prac- titioner, produced a modest improvement in lesion severity, although this medicine had to be discontinued due to antibiotic-associated diarrhoea. The client is embarrassed by the condition and feels the acne is dampening his self-image and self-esteem. Medical history Family history Father had severe facial acne and scarring, paternal grandmother has type 2 diabetes mellitus, maternal grandfather has ischaemic heart disease. Allergies Bee venom. Medications Five per cent benzoyl peroxide ointment twice daily. Medical conditions Lactose intolerance. Surgical or investigational procedures Tonsillectomy and adenoidectomy (1999). Lifestyle history Tobacco use Nil. Alcohol consumption Nil. Illicit drug use Nil. Diet and fluid intake Breakfast Large glass of full-cream milk. Morning tea Apple, muesli bar. Lunch Two sandwiches, made with white bread and spread with peanut butter or Vegemite®. Afternoon tea Sweet biscuits, toasted white bread spread with Vegemite®. ❨171
  24. 24. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE Diet and fluid intake Dinner Spaghetti bolognaise, fettuccine carbonara, lasagne, supreme pizza. Fluid intake 1 cup of cordial daily, 1 cup of juice daily, 2 cups of water daily, 1 cup of milk daily. Food frequency Fruit 1–2 serves daily Vegetables 1–2 serves daily Dairy 2 serves daily Cereals 7 serves daily Red meat 6 serves a week Chicken 1 serve a week Fish 0 serves a week Takeaway/fast food 2–3 times a week Quality and duration of sleep Continuous sleep; average duration is 6–7 hours. Frequency and duration of exercise Is not engaged in any sporting activities, is transported to and from school by car, engages in active play or exercise less than 1 hour a day, and sedentary activities (out of school) more than 5 hours a day. Socioeconomic background The client is Australian-born with an Australian-born mother and Italian-born father, who are married. He lives with his parents. His father works full time; his mother is a stay-at-home parent. He is studying Year 11 at a private school (which the client considers to be moderately stressful), is Roman Catholic and has three younger siblings, aged 9, 12 and 14. The client states he lives in a happy and supportive household. Physical examination Inspection Multiple acneiform lesions are present on the forehead (18 lesions – papules and pustules), nose (6 lesions – open comedones), left cheek (3 lesions – papules), right cheek (4 lesions – closed comedones and papules) and upper back (17 lesions – closed comedones and papules). There is no bleeding, scarring, oedema, nodules, excoriation or ulceration. Finger and toenails are strong and intact, with no notable markings. Olfaction There is no abnormal odour to the lesions or patient. Palpation Skin to the face and upper back is oily. Papules and pustules are warm. The surround- ing skin demonstrates good turgor, moisture and mobility. Percussion Not applicable. Auscultation Subcutaneous crepitus is not detectable. Additional signs Client is afebrile (36.4°C per oral) and overweight (body mass index (BMI) is 27 kg/m2). 172❩
  25. 25. 1 ❨ Case 1: Acne vulgaris/rosacea Clinical assessment tools Using the Bikowski acne severity index (BASI), facial acne was graded as follows: forehead (moderate grade III acne), nose (mild grade II acne) and left and right cheeks (mild grade II acne). Diagnostics CAM practitioners may request, perform and/or interpret findings from a range of diagnostic tests in order to add valuable data to the pool of clinical information. While several investigations are pertinent to this case (as described below), the decision to use these tests should be considered alongside factors such as cost, convenience, comfort, turnaround time, access, practitioner competence and scope of practice, and history of previous investigations. Pathology tests The use of culture and sensitivity tests to detect the presence of P. acnes is not a reli- able diagnostic for acne as this bacterium is a normal resident of human skin. Testing serum androgen levels is also unreliable as most patients with acne demonstrate normal androgen levels.1 Low plasma concentrations of vitamin A are reported in people with acne.7 Assess- ing hair or serum vitamin A levels may help to determine whether vitamin A deficiency is implicated in this condition. Radiology tests Not applicable. Functional tests Not applicable. Invasive tests Not applicable. Miscellaneous tests Not applicable. Diagnosis Clusters of data extracted from the health history, clinical examination and pertinent diagnostic test results point towards the following differential CAM diagnosis. Acne (actual), related to genetic predisposition (client has a family history of acne), hormonal imbalance (androgen and growth hormone levels are typically elevated dur- ing adolescence), high glycaemic load diet (client’s diet largely consists of highly refined carbohydrates; acne is exacerbated by chocolate consumption), P. acnes colonisation (the severity of acneiform lesions improved following antibiotic treatment) and emo- tional stress (acne is aggravated by stress). Planning The goals and expected outcomes that best serve the client’s needs and that are most relevant to the presenting case (as determined by the clinical assessment and CAM diagnoses) are as follows. Goal 1 Client will be free from acneiform lesions (client’s primary concern is the long- standing acne). Expected outcomes Based on the degree of improvement reported in clinical studies that have used CAM interventions for the management of acne,8–11 the following are anticipated. 1 Client will demonstrate a forty-five per cent decrease in the baseline number of acneiform lesions on the forehead, nose, cheeks and/or upper back in 9 weeks or by dd/mm/yyyy (measured by the severity component of the BASI). ❨173
  26. 26. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE 2 Client will exhibit a forty-five per cent reduction in the baseline severity of acne- iform lesions in 9 weeks, or by dd/mm/yyyy (measured by the grade component of the BASI). 3 Client will report a twenty-five per cent improvement in baseline self-esteem in 9 weeks or by dd/mm/yyyy (measured by a 0–10 visual analogue scale). Application The range of interventions reported in the CAM literature that can be used in the treatment of acne are appraised below. Diet Low glycaemic-load diet (Level II, Strength A, Direction +) The consumption of foods with a high glycaemic index or glycaemic load may, as dis- cussed earlier, contribute to the pathogenesis of acne. Hence, the substitution of high glycaemic-load foods such as sweetened, refined and highly processed products with foods that have a low glycaemic-load, such as wholegrains and fruits with edible skins or are high in protein, including eggs and lean meat, may be of benefit to those suffering from acne. Indeed, two controlled clinical trials have shown young males who follow a 12-week low glycaemic-load diet demonstrate a significant reduction in insulin resistance, fasting insulin, free androgen levels, BMI, total acneiform lesion counts and inflammatory lesion counts when compared to those consuming a high glycaemic-load diet.9,10 Lifestyle Relaxation therapy (Level II, Strength B, Direction +) Psychological stress is positively correlated with the severity of acne.12,13 It is there- fore reasonable to assume that successful attempts at reducing stress could lead to clinical improvements in acne. This assumption was tested in a small randomised controlled trial (RCT) of thirty dermatology patients with acne vulgaris, and found 6 weeks of biofeedback-assisted relaxation and cognitive imagery was significantly more effective than attention-comparison and medical control at reducing acne severity.14 Further research is now needed to determine whether similar effects can be observed using other stress reduction techniques, including meditation, yoga and tai chi. Nutritional supplementation Ascorbic acid (Level II, Strength C, Direction +) Vitamin C has the potential to attenuate the pathogenesis of acne by reducing cuta- neous lipid peroxidation, P. acnes replication15 and serum C-reactive protein (CRP) levels (a marker of acute inflammation).16 Findings from an open comparative study add some support to this theory, with topically applied five per cent sodium ascorbyl phosphate (SAP) (a vitamin C derivative) twice daily for 12 weeks shown to be more effective than five per cent benzoyl peroxide in reducing the number of inflamma- tory and non-inflammatory acneiform lesions in 49 subjects.15 A small double-blind RCT (n = 30) also found five per cent SAP lotion (applied twice daily for 8 weeks) to reduce inflammatory lesion count in adults with acne vulgaris, although the difference between the SAP and 0.2 per cent retinol groups was not statistically significant.17 Given that studies have used different active controls, no firm conclusions can yet be made about the efficacy of topical SAP in acne. Nicotinamide (Level II, Strength B, Direction +) Vitamin B3 reduces inflammatory mediator release18 and, as such, may play a role in the treatment of inflammatory skin disorders. Several controlled clinical trials have confirmed this, with topically administered nicotinamide gel (four per cent) found to be as effective as antibiotic gel in reducing the number and severity of inflamed acne- iform lesions.11,19 Whether this affect can be demonstrated with orally administered vitamin B3 is not yet clear. 174❩
  27. 27. 1 ❨ Case 1: Acne vulgaris/rosacea Vitamin A (Level II, Strength B, Direction +) Collagen synthesis, phagocytosis, antibody production and epithelial cell differentia- tion are key functions of vitamin A.20 Given these actions and the significantly lower plasma concentration of vitamin A reported in people with acne,7 it is not surpris- ing that many studies (albeit methodologically limited studies) have found synthetic vitamin A derivatives to be effective at reducing the severity of acne vulgaris when administered as oral or topical preparations.21–26 Whether these effects translate to betacarotene and/or natural vitamin A is not yet certain. Zinc (Level II, Strength C, Direction o) Zinc modulates inflammatory and immune activity27 and demonstrates antimicrobial activity against Propionibacterium strains.28 While low serum and epidermal zinc con- centrations have been reported in people with acne vulgaris,29,30 the evidence is not conclusive. Likewise, evidence from trials investigating the clinical efficacy of zinc in acne has not been consistent.31–35 Lactobacillus spp., omega 3 fatty acids, selenium and vitamin E These supplements exhibit myriad effects that are desirable in the management of acne, including anti-inflammatory and immunomodulatory activity; however, there is insufficient clinical evidence to justify the administration of these agents in individuals with acne. Herbal medicine Commiphora molmol (level II, strength C, direction o) Myrrh has long been used as an anti-inflammatory, vulnerary and antimicrobial herb. These effects appear to be of some benefit to patients with nodulocystic acne, with a small RCT of 20 patients finding oral Gugulipid extract (equivalent to 25 mg guggulsterone), administered twice daily for 3 months, to be as effective as oral tetracycline at reducing the number of inflamed acneiform lesions.36 No firm conclusions can be made about the efficacy of myrrh until further evidence from larger studies becomes available. Vitex agnus-castus (level III-1, strength D, direction +) Chaste tree may exert a mild antiandrogenic effect by reducing serum prolactin lev- els37 and thus may attenuate the sequence of events leading to the manifestation of acne. This action may explain why an earlier controlled trial of 161 subjects found chaste tree treatment to be significantly superior to placebo at improving the signs of acne at 12 weeks.38 In view of the paucity of corroborating data and the insufficient details of the study, these results should be interpreted with caution. Other herbs Arctium lappa (burdock), Galium aparine (cleavers), Trifolium pratense (red clover), Rumex crispus (yellow dock) and Scrophularia nodosa (figwort) have long been used as treatments for skin complaints because of their depurative action. Experimental data suggest that Glycyrrhiza glabra (licorice) and Echinacea spp. (echinacea) may also be indicated for the treatment of acne because of their anti-inflammatory, immunomodulatory and antimicrobial activity against P. acnes.39,40 Despite the availability of traditional and/or experimental evidence in this area, there is insuffi- cient clinical evidence to support or refute the effectiveness of these herbs in acne. Other Acupuncture (level II, strength D, direction +) Many case reports have been published on the effectiveness of acupuncture in acne;41–43 however, given the methodological limitations of these reports, no firm conclusions can be drawn. A more recent RCT of 52 patients with acne conglobata adds much-needed rigour to this body of evidence. Four weeks of treatment, daily encircling acupuncture, together with twice weekly venesection and cupping, was found to be as effective as orally administered isotretinoin (10 mg three times a day) ❨175
  28. 28. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE at reducing the signs of acne, and superior to isotretinoin at lowering serum inter- leukin-6 levels.44 The risk of placebo bias in this trial and the unknown confounding effect of venesection and cupping makes the translation of these findings into clinical practice difficult. Melaleuca alternifolia (aromatherapy) (level II, strength B, direction +) Indigenous Australians traditionally used tea tree for its anti-inflammatory, antimicro- bial and antiseptic properties. These effects, as well as the sensitivity of P. acnes to tea tree oil,45 indicate that tea tree may be effective as a treatment for acne. Find- ings from a systematic review of one RCT (n = 124) support this proposition,46 with the topical application of five per cent tea tree oil gel found to be as effective as five per cent benzoyl peroxide at reducing the number and severity of acneiform lesions, albeit with a relatively slower onset of action.47 Similar outcomes were observed in a more recent RCT (n = 60) that compared five per cent tea tree oil gel to placebo in 60 adolescents and young adults.8 Chiropractic, homeopathy, massage, osteopathy and reflexology There is insufficient clinical evidence to support the use of these therapies in the management of acne. CAM prescription The CAM interventions that are most appropriate for the management of the pre- senting case – that is, they target the planned goals, expected outcomes and CAM diagnoses, they are supported by the best available evidence, they are pertinent to the client’s needs and they are most relevant to CAM practice – are outlined below. Primary treatments • Commence low-glycaemic-load (GL) diet (e.g. substitute high-GL foods, such as sweetened, refined and highly processed products, including chocolate, with foods that have a low-GL, including wholegrains and fruits with edible skins) (client consumes a high-GL diet; the consumption of a low-GL diet is shown to be effective in reducing the number and severity of acneiform lesions). • Commence relaxation therapy (e.g. progressive muscle relaxation and guided imagery), at least 30 minutes twice a week (stress aggravates the client’s acne; relaxation therapy induces the relaxation response and may be helpful in de- creasing the severity of acne). Consider one of the following biological interventions: 1 Four per cent nicotinamide gel, applied to lesions twice a day (nicotinamide gel is effective in reducing the number and severity of inflamed acneiform lesions). 2 Five per cent tea tree oil gel, applied to lesions daily (tea tree oil gel is effective in reducing the number and severity of acneiform lesions). Secondary treatments Consider oral gugulipid extract, equivalent to 25 mg guggelsterone, twice a day (P. acnes colonisation may be contributing to the client’s acne; C. molmol is an antimi- crobial and anti-inflammatory herb, and may help to reduce the number of inflamed acneiform lesions). Referral • Refer the client to a general practitioner, family physician, endocrinologist or dermatologist if the condition deteriorates, if serious pathology is suspected (such as Cushing’s syndrome or diabetes mellitus) or if a serious complication arises (such as an abscess or skin ulceration). • Refer the client to another CAM practitioner if acne vulgaris, or the treatment of acne vulgaris, is outside the clinician’s area of expertise. • Liaise with the general practitioner about the client’s overall management plan. 176❩
  29. 29. 1 ❨ Case 1: Acne vulgaris/rosacea Review To determine whether pertinent client goals and expected outcomes have been achieved at follow-up, and if any aspects of the client’s care need to be improved, consider the factors listed in Table 8.2 (chapter 8) and the questions listed below. • Was there a reduction in the severity component of the BASI for the four facial regions and upper back? • Was there a reduction in the grade component of the BASI for the four facial regions and upper back? • Was there an improvement in client self-esteem? • Has there been a general reduction in the glycaemic index or glycaemic load of foods consumed since the initial consultation? • Has the need for benzoyl peroxide decreased? References 1. Cargnello JA. (2005) Acne: what’s new? In: Marks R, 14. Hughes H et al (1983) Treatment of acne vulgaris by editor. Dermatology. 2nd ed. Sydney: Australasian biofeedback relaxation and cognitive imagery. Journal Medical Publishing Company. of Psychosomatic Research, 27(3): 185–91. 2. Cappel M. Mauger D. Thiboutot D. (2005) Correlation 15. Klock J et al (2005) Sodium ascorbyl phosphate shows between serum levels of insulin-like growth factor 1, in vitro and in vitro efficacy in the prevention and treat- dehydroepiandrosterone sulfate, and dihydrotestoster- ment of acne vulgaris. International Journal of Cosmetic one and acne lesion counts in adult women. Archives of Science, 27(3): 171–6. Dermatology, 141: 333–8. 16. Wannamethee SG et al (2006) Associations of vitamin 3. Buchanan P. Courtenay M. (2006) Prescribing in der- C status, fruit and vegetable intakes, and markers of in- matology. Cambridge: Cambridge University Press. flammation and hemostasis. American Journal of Clini- 4. Porter R et al, editors. (2008). The Merck manual. cal Nutrition, 83(3): 567–74. Whitehouse Station: Merck Research Laboratories. 17. Ruamrak C. Lourith N. Natakankitkul S. (2009) Com- 5. Feldman S et al (2004) Diagnosis and treatment of acne. parison of clinical efficacies of sodium ascorbyl phos- American Family Physician, 69: 2123–30. phate, retinol and their combination in acne treatment. 6. Cordain L. (2005) Implications for the role of diet in International Journal of Cosmetic Science, 31(1): 41–6. acne. Seminars in Cutaneous Medicine and Surgery, 18. Namazi MR. (2003) Nicotinamide: a potential addition to 24(2): 84–91. the anti-psoriatic weaponry. FASEB Journal, 17: 1377–9. 7. El-Akawi Z. Abdel-Latif N. Abdul-Razzak K. (2006) 19. Shalita AR et al (1995) Topical nicotinamide compared Does the plasma level of vitamins A and E affect acne with clindamycin gel in the treatment of inflammatory condition? Clinical and Experimental Dermatology, acne vulgaris. International Journal of Dermatology, 31(3): 430–4. 34(6): 434–7. 8. Enshaieh S et al (2007) The efficacy of 5% topical tea 20. Leach MJ. (2004) A critical review of natural therapies tree oil gel in mild to moderate acne vulgaris: a ran- in wound management. Ostomy/Wound Management, domized, double-blind placebo-controlled study. Indian 50(2): 36–51. Journal of Dermatology, Venereology and Leprology, 21. Fatum B. Hansen HHV. Mortensen E. (1980) Topical 73(1): 22–5. treatment of acne vulgaris with the vitamin A acid deri- 9. Smith RN et al (2007) A low-glycemic-load diet vate motretinide (Tasmaderm®), tretinoin (Airol®) and improves symptoms in acne vulgaris patients: a ran- a placebo cream. Ugeskrift for laeger, 142(51): 3364–6. domized controlled trial. American Journal of Clinical 22. Gandola M et al (1976) Topical vitamin A acid in the Nutrition, 86(1): 107–15. treatment of acne vulgaris (a controlled multicenter 10. Smith R et al (2008) A pilot study to determine the trial). Archives for Dermatological Research, 255(2): short-term effects of a low glycemic load diet on hor- 129–38. monal markers of acne: a nonrandomized, parallel, 23. Lucky AW et al (1998) Comparative efficacy and safety controlled feeding trial. Molecular Nutrition and Food of two 0.025% tretinoin gels: results from a multicenter Research, 52(6): 718–26. double-blind, parallel study. Journal of the American 11. Weltert Y et al (2004) Double-blind clinical assessment Academy of Dermatology, 38(4): S17–23. of the efficacy of a 4% nicotinamide gel (Exfoliac NC 24. Peck GL et al (1982) Isotretinoin versus placebo in the Gel) versus a 4% erythromycin gel in the treatment of treatment of cystic acne. A randomized double–blind moderate acne with a predominant inflammatory com- study. Journal of the American Academy of Dermatol- ponent. Nouvelles Dermatologiques, 23(7): 385–94. ogy, 6(4 Suppl 2): 735–45. 12. Schulpis K et al (1999) Psychological and sympatho- 25. Schumacher A. Stuttgen G. (1971) Vitamin A acid in adrenal status in patients with cystic acne. Journal of the hyperkeratoses, epithelial tumors and acne. Deutsche European Academy of Dermatology and Venereology, Medizinische Wochenschrift, 96: 1547–51. 13(1): 24–7. 26. Shalita AR et al (1999) Tazarotene gel is safe and 13. Yosipovitch G et al (2007) Study of psychological effective in the treatment of acne vulgaris: a multi- stress, sebum production and acne vulgaris in adoles- center, double-blind, vehicle-controlled study. Cutis, cents. Acta Dermato-Venereologica, 87(2): 135–9. 63(6): 349–54. ❨177
  30. 30. CLINICAL DECISION MAKING IN COMPLEMENTARY AND ALTERNATIVE MEDICINE 27. Kahmann L et al (2008) Zinc supplementation in the 39. Nam C et al (2003) Anti-acne effects of Oriental herb elderly reduces spontaneous inflammatory cytokine extracts: a novel screening method to select anti-acne release and restores T cell functions. Rejuvenation agents. Skin Pharmacology and Applied Skin Physiol- Research, 11(1): 227–37. ogy, 16(2): 84–90. 28. Fluhr JW et al (1999) In-vitro and in-vivo efficacy of 40. Sharma M et al (2008) Echinacea extracts contain sig- zinc acetate against propionibacteria alone and in com- nificant and selective activities against human patho- bination with erythromycin. Zentralblatt fur Bakteriolo- genic bacteria. Pharmaceutical Biology, 46(1–2): gie, 289(4): 445–56. 111–16. 29. Amer M et al (1982) Serum zinc in acne vulgaris. Inter- 41. Ding LN. (1985) 50 cases of acne treated by puncturing national Journal of Dermatology, 21(8): 481–4. acupoint dazhui in combination with cupping. Journal 30. Michaelsson G. Ljunghall K. (1990) Patients with der- of Traditional Chinese Medicine, 5(2): 128. matitis herpetiformis, acne, psoriasis and Darier’s dis- 42. Hou H. Wu T. (2002) Fifty-six cases of acne treated by ease have low epidermal zinc concentrations. Acta auricular needle-embedding. Journal of Traditional Chi- Dermato-Venereologica, 70(4): 304–8. nese Medicine, 22(2): 115–16. 31. Agrawal P et al (1985) Oral zinc in acne vulgaris (a 43. Xu YH. (1989) Treatment of acne with ear acupuncture double blind evaluation). Indian Journal of Dermatol- – a clinical observation of 80 cases. Journal of Tradi- ogy, Venereology and Leprology, 51(1): 38–9. tional Chinese Medicine, 9(4): 238–9. 32. Dreno B et al (1989) Low doses of zinc gluconate 44. Liu CZ. Lei B. Zheng JF. (2008) Randomized control for inflammatory acne. Acta Dermato-Venereologica, study on the treatment of 26 cases of acne conglobata 69(6): 541–3. with encircling acupuncture combined with venesection 33. Goransson K. Liden S. Odsell L. (1978) Oral zinc in and cupping. Zhen Ci Yan Jiu, 33(6): 406–8. acne vulgaris: a clinical and methodological study. Acta 45. Raman A. Weir U. Bloomfield SF. (1995) Antimicro- Dermato-Venereologica, 58(5): 443–8. bial effects of tea-tree oil and its major components on 34. Orris L et al (1978) Oral zinc therapy of acne. Staphylococcus aureus, Staph. epidermidis and Propi- Absorption and clinical effect. Archives of Dermatol- onibacterium acnes. Letters in Applied Microbiology, ogy, 114(7): 1018–20. 21(4): 242–5. 35. Verma KC. Saini AS. Dhamija SK. (1980) Oral zinc 46. Ernst E. Huntley A. (2000) Tea tree oil: a systematic sulphate therapy in acne vulgaris: a double-blind trial. review of randomized clinical trials. Forschende Kom- Acta Dermato-Venereologica, 60(4): 337–40. plementarmedizin und Klassische Naturheilkunde, 36. Thappa DM. Dogra J. (1994) Nodulocystic acne: oral 7(1): 17–20. gugulipid versus tetracycline. Journal of Dermatology, 47. Bassett IB. Pannowitz DL. Barnetson RS. (1990) A 21(10): 729–31. comparative study of tea-tree oil versus benzoylperox- 37. Bone K. (2003) A clinical guide to blending liquid ide in the treatment of acne. Medical Journal of Austra- herbs. St Louis: Churchill Livingstone. lia, 153(8): 455–8. 38. Amann W. (1967) Improvement of acne vulgaris fol- lowing therapy with Agnus castus (Agnolyt). Therapie der Gegenwart, 106(1): 124–6. 178❩